FactPower: Facts, figures, and talking points for Resistance activists.
The Path Forward for Health Care Reform: First Bipartisanship, Then Medicare for All
We all fought heroically to educate both constituents and lawmakers and to block repeal of the ACA on July 27 and 28. It came down to three dissenting GOP senators (our heroes), without whom we would have lost: John McCain (R, AZ), Susan Collins (R, ME), and Lisa Murkowski (R, AK). However, we all know our victory is fragile, and it will not last. It saddens us all that Sen. McCain has brain cancer of a variety that is almost never curable. Realistically, his time in Congress is limited, and the median survival time does not favor his lasting until the new Congress is inaugurated January 20, 2019. If he dies, the Governor of Arizona will appoint a new senator who will happily vote to repeal the ACA. And then we could be in trouble.
Many have turned to FactPower for guidance as to the future of our struggle to save the ACA and eventually achieve universal healthcare. There are several moving parts, and they can be confusing in their totality:
John McCain’s cancer is the ticking time bomb that limits our time window.
The elections of 2018 offer hope of taking back at least one house of Congress.
The Senate parliamentarian has ruled that the reconciliation process for the ACA will expire September 30.
The Senate HELP committee will begin a bipartisan process to develop fixes to the ACA, beginning with hearings September 5. At least 4 bipartisan plans to fix the ACA have already been proposed.
Sens. Lindsay Graham (R, SC) and Bill Cassidy (R, LA) introduced a repeal/replace bill that has never been put to a vote.
Sens. Bernie Sanders (I, VT) and Kamala Harris (D, CA) will soon introduce a “Medicare for All” bill.
The GOP has other plans of attack, such as deep budgetary cuts to Medicaid and lax review of Section 1332 waivers.
Failure of the ACA, without any replacement in place, would be catastrophic. Tens of millions of Americans would lose their insurance, and tens of thousands would die every year. Yes, I said “die.”
Let’s discuss these issues separately:
THE TICKING TIME BOMB: This cannot be understated: We are dealing with a ticking time bomb, as one of our three heroes, Sen. McCain, will not be serving in Congress much longer. We have as long as Sen. McCain survives to fix the ACA -- well enough that Republicans abandon their efforts to repeal it. If we cannot do this, then the ACA could be repealed within days of Sen. McCain’s passing. (Please re-read this paragraph.)
TAKING BACK CONGRESS: Will Democrats be able to take back one house of Congress (or even win one more Senate seat) before Sen. McCain's passing? That would prevent Republicans from repealing the ACA even after he is no longer serving. Unfortunately we don't know whether Sen. McCain can last that long. Physicians tell us the odds don't favor it, perhaps even for someone as tough as our war hero. And we don’t know whether Democrats will control either house in 2019. We can hope, but “hope” is never a viable strategy.
THE END OF RECONCILIATION: Many are quick to celebrate the Senate Parliamentarian’s decision that the reconciliation rules by which the ACA could be repealed and possibly replaced in the Senate will draw to a close on September 30. After this date Republicans would need 60 votes (no longer 51) for passage. For a bill to be passed under reconciliation after this date, the entire process would need to start again in both houses.
Would that be difficult? Absolutely not. Congress could retrace all their steps very quickly to run the same “skinny repeal” through the Senate under a new reconciliation procedure. Once passed, the bill would be quickly signed into law. This could all happen within days – or hours.
Remember that Republicans are no longer concerned about passing a “good” bill, and they no longer have any expectation of selling the merits of the bill to their constituents. In the wee hours of July 28, they were ready to pass the “skinny repeal” and throw it on the president’s desk. And the president was ready to sign it, despite his insistence the bill must have “heart.” All the GOP wants right now is a quick legislative “victory.”
A BIPARTISAN SOLUTION: Republicans claim the ACA is falling apart, but they are discovering they can’t destroy the law – or repeal it – no matter how hard they try. Their only credible path forward is to fix the considerable damage they have caused. For Democrats, the only path forward, within the time period defined by Sen. McCain’s cancer, is to collaborate in this process. Once the damage is fixed, Republicans will probably stop droning on about failing markets and leave this toxic issue alone. Otherwise they would look impotent in the 2018 elections.
There are several bipartisan efforts underway:
The Senate HELP Committee, under the leadership of Sens. Lamar Alexander (R, TN) and Patty Murray (D, WA), is holding hearings starting September 5, with the intent of exploring solutions and drafting a bill to stabilize markets and fix problems that have arisen. This is our best hope of a path forward.
The House Problem Solvers Caucus, a bipartisan body, has developed recommendations for fixing the ACA. Unfortunately this caucus has no influence with the House leadership, so its recommendations are unlikely to be taken seriously as a House bill.
Governors Kasich (R, OH) and Hickenlooper (D, CO) have co-authored a letter to House and Senate leadership, offering their recommendations.
There is considerable convergence of thought on several of the recommendations. The HELP Committee is likely to draft a bill specifically to address the measures for which there is broad consensus. Passing such a bill will require broad support from Democrats and moderate Republicans. It may even be necessary to amass a veto-proof majority, as many expect the president would not support any plan that would fix the ACA. Sen. Alexander hopes to have a bill passed by September 27, the deadline for marketplace contracts between insurers and the federal government.
We will see what obstacles await a bipartisan fix in the House. By the Hastert Rule, a majority of Republicans must support any bill before it is brought to a vote. We may have to pull out all the stops again to push our GOP representatives into supporting such a bill. We will have the advantage of doing this at the beginning of election season, when they would look really bad for resisting needed reforms.
GRAHAM-CASSIDY (SA 391): The most harmful of the Republican bills was a late arrival, drafted during the August recess. It has never been scored by the CBO, debated, or brought to a vote. The Graham-Cassidy bill would repeal the ACA and divert all the taxpayer funding to the states, so that they could all implement their own health insurance programs. This bill borders on political erotica to the far right. It could easily draw enthusiasm and support away from the more mundane issues of fixing what we already have. On September 6, Sen. McCain said he would support the bill, but only after it has gone through committee under regular order. Asked whether the bill "has legs" before September 30, Sen. McCain indicated he thinks it does. Shortly thereafter he walked back the statement, saying he supports the concept but will not take a position until seeing the final legislation. The bill has perhaps become a credible threat to the ACA.
“MEDICARE FOR ALL”: Medicare expansion has become a hot topic among progressives recently, and Sen. Sanders will soon introduce a “Medicare for All” bill. In the House, Rep. John Conyers (D, MI) had already introduced a similar bill that was later introduced in the Senate by Republican Sen. Steve Daines (MT). Sen Sanders voted “present” for the bill (abstaining), instead of voting “yea.” If that confuses you, you’re not alone. Sen. Sanders is a very smart guy and a venerable lawmaker. He was fully aware there is ZERO chance such a bill would pass with this Congress and president, so there was nothing to be gained by voting in favor of the bill at that time. And he wasn’t going to be played by Senate Republicans (which made them furious). So why is he introducing a bill that he wouldn’t support with a “yea” vote only 5 weeks ago? He’s contributing to an important national discussion, refining details of the plan, and bringing the plan to the forefront as a 2018 election issue. (Remember, he is running for reelection in 2018). Because this issue is on the table, Democrats will increasingly be electing lawmakers who will support this goal once it becomes a viable option. This is a direction we need to go, and we need to start this serious discussion.
However, the time for “Medicare for All” is not now. For now, there are too many details to be worked out. Sen. Sanders has fleshed out his plan quite well, including how it would be funded. However, the aggressive taxation of the wealthy, alone, would have virtually every Republican screaming, “over my dead body!” There’s much work yet to be done.
“MEDICARE FOR 55”: Sen. Stabenow (D, MI) has introduced her “Medicare for 55” bill, which would lower the age of eligibility for the program. This plan is nothing new, having previously been introduced by other lawmakers. Like Sanders’ “Medicare for All” bill, it probably has little chance of passage. However, don’t be surprised if it crops up in the debate over how to fix the ACA. Unlike Sanders’ plan, which would replace the ACA entirely, “Medicare for 55” could supplement it, indirectly reducing insurance costs for younger Americans. Under the ACA, premiums from young, healthy people are used to offset the higher health expenses of older people. “Medicare for 55” would eliminate that burden. Also, Medicare would be less expensive than private insurance for older Americans. This would of course come at a higher cost to taxpayers, which is why it is highly unlikely to pass in an Republican-controlled government.
ALTERNATIVE PLANS OF ATTACK: Republicans continue to develop other plans of attack. The latest administration efforts are to make steep cuts in Medicaid funding, which would result in untold millions of people losing access to healthcare. We also have to deal with the problem of Sec. 1332 waivers, which allow states to implement their own health insurance systems. (We can speculate many states would want to cheapen insurance, both in price and quality, while diminishing subsidy support for low income people.) Under current law, a state can obtain a Sec. 1332 waiver only if its replacement plan provides coverage that is at least as comprehensive to at least as many people. The problem is that this determination would be made by Secretary of Health and Human Services Tom Price (appointed by the president), and it would probably be done with a wink and a nod.
IF WE FAIL, PEOPLE WILL DIE: According to the Congressional Budget Office (CBO), repeal of the ACA would result in 17 million Americans losing their insurance immediately, growing to 32 million by 2026. We know from a 2014 study published in the Annals of Internal Medicine that one in every 820 uninsured people dies every year simply for lack of insurance. Therefore, after a repeal, 20,731 Americans would die per initially, growing to 39,024 per year by 2026. Put in more familiar terms, that’s a September 11 event every month.
For this reason, we cannot let ourselves get too distracted by daydreams of Medicare for All. It is an election issue and a long term goal, but nothing else. There are many activists, mostly inexperienced, who have become very excited about this and other single-payer proposals. They are circulating petitions. They see this shaping up as our next health care battle. It is not.
Those activists who want to fight now for “single-payer” or “Medicare for All” will have to wait at least until 2021 (the earliest President Trump/Pence/Ryan might be voted out of office) before there is any chance at all of passing such a plan. And that plan could not be implemented until 2022 (the first year after the presidential inauguration). Using the CBO’s year-by-year figures, 92 million subscriber-years of insurance would be lost. That would result in 112,195 American deaths, for no other reason than loss of insurance. That would be the human cost of dropping the ball on a fix to the ACA, while daydreaming about Medicare for All. Letting that happen would be callous and immoral.
We need to focus squarely on the present:
Bipartisan work in the HELP Committee may fix the damage done to the ACA.
Graham-Cassidy has become a credible threat, and we need to nip any notions of passing it in the bud.
We need to fight against Medicaid budget cuts.
We need to explore remedies to the Sec. 1332 problem.
GOING FORWARD: We all know the ACA is only a temporary measure. We are applying pressure to a wound to stop the bleeding, but there is much to do to get the patient stabilized. Currently, there are 26 million uninsured Americans. Of those, 31,707 die every year. Those are the stakes going forward. Only universal health care will save those lives, and that will probably take the form of Medicare for All. However, we cannot fight for Medicare for All until we have elected lawmakers willing to pass it. That process starts with the 2018 elections. But for now, we MUST stay laser-focused on saving the ACA (and Medicaid funding). Because American lives depend on it.
[We are grateful to all the people who offered their input into this article.] (September 5, 2017. Updated September 6 with news that Sen. McCain would support Graham-Cassidy)